(69) Secondary Overtriage in Isolated Midface Fractures: Can Unnecessary Patient Transfers be Avoided?

Abstract: Statement of the problem: Unnecessary interfacility hospital transfers impose a considerable financial and resource burden on both patients and trauma centers. Patients with maxillofacial injuries are frequently transferred for specialist evaluation, despite growing evidence that interfacility transfer is unnecessary in this patient population. While the rates of operative intervention for mandible fractures have increased over recent years, isolated midface fractures most often are non-operative, and typically do not require intervention at the time of presentation. Previous studies to date have used single center data to examine secondary overtriage as it pertains to any maxillofacial injury. This study aims to use a nationwide database to determine the necessity of transfer for patients sustaining isolated midface injuries only.

Materials and methods: Patients presenting to the emergency department from 2017 to 2022 were identified using the National Trauma Data Bank (NTDB). Only patients presenting as a transfer from an outside facility sustaining an isolated facial fracture were included. The outcome variable was patient admission. The primary predictor variable was midface fracture. Secondary predictor variables included patient demographics, transportation mode, primary payment method, hospital type, mandible fracture, and pre-existing patient conditions. Descriptive, bivariate analysis and multivariate logistic regression models were used to identify factors independently associated with admission in patients with isolated facial fractures undergoing transfer from another hospital for evaluation.


Results: After sustaining an isolated facial fracture, 3,838 patients underwent transfer from another hospital. Of those, 1,502 (39.1%) were admitted following transfer. Less than one-third of patients presenting with isolated midface fractures were admitted (32.1%). In multivariate analysis, patients with an isolated midface fracture were significantly less likely to be admitted following transfer (OR 0.44, 95% CI 0.33-0.59, P = .000). Alternatively, Medicaid payers (OR 1.44, 95% CI 1.01-2.05, P = .047), patients on anticoagulants (OR 2.72, 95% CI 1.21-6.12, P = .016), patients with diabetes (OR 1.84, 95% CI 1.03-3.31, P= .041), patients with COPD (OR 2.36, 95% CI 1.16-4.83, P = .018), patients with reported substance abuse (OR 2.80, 95% CI 1.63-4.81, P= .000), patients transferred via helicopter (OR 3.87, 95% CI 1.29-11.60, P = .016), and patients with mandible fractures (OR 2.25, 95% CI 1.70-3.00, P = .000) were significantly more likely to be admitted following transfer.

Outcomes and conclusion: Our analysis reveals a significant proportion of patients presenting with stable, isolated midface facial trauma may benefit from appropriate management without the need for emergent transfer. This observation underscores the potential for optimizing current transfer protocols to mitigate unnecessary healthcare expenditures and optimize the allocation of medical resources. By revising facial trauma transfer guidelines, we may help to diminish the increasing burden on emergency departments, thereby augmenting the efficiency of patient-care delivery.

References
Pontell ME, Steinberg JP, Mackay DR, Rodriguez ED, Strong EB, Olsson AB, Kriet JD, Kelly KJ, Ochs MW, Taub PJ, Desai SC, MacLeod S, Susarla S, Tollefson TT, Schubert W, Drolet BC, Golinko MS. Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus. Plast Reconstr Surg. 2022 Oct 1;150(4):835e-846e.

Lee CC, Wang TT, Hajibandeh JT, Peacock ZS. Interfacility Emergency Department Transfer for Midface Fractures in the United States. J Oral Maxillofac Surg. 2023 Feb;81(2):172-183.